What is retrospective review?
Retrospective review is the process of determining coverage after treatment has been given. These evaluations occur by:
- Confirming member eligibility and the availability of benefits
- Analyzing patient care data to support the coverage determination process
- Receiving supporting clinical documentation from providers with the payment request
When retrospective review is available
Retrospective review is available when:
- Precertification/notification requirements were met at the time the service was provided, but the dates of service do not match the submitted claim.
- Aetna converts from secondary payer to primary payer at the time of inpatient claims adjudication.
Retrospective review is not available when claims are for:
- Elective ambulatory or inpatient services on the Aetna Participating Provider Precertification List or the Aetna Behavioral Health Precertification List for which precertification did not occur before providing the service
- Emergency inpatient services on the previously mentioned precertification lists that did not meet notification requirements (notification of inpatient admissions is required within one business day of the admission date)
- Services not included on a precertification list
- Services that do not require precertification under the terms of a member’s plan
The retrospective review process
The retrospective review process includes:
- The identification and referral of members, when appropriate, to covered specialty programs, including Aetna Health ConnectionsSM case management and disease management, behavioral health, National Medical Excellence Program®, and women’s health programs, such as the Beginning Right® Maternity Program and the infertility program.
- The identification and referral of potential quality and/or utilization issues for follow-up
- The identification, referral and review (as applicable) of patient safety events
Retrospective review does not include a preferred/in-network level of benefits determination for routine or scheduled services performed by a nonparticipating provider.
For these purposes, “coverage” means either the determination of (i) whether or not the particular service or treatment is a covered benefit pursuant to the terms of the particular member's benefits plan, or (ii) where a provider is required to comply with Aetna's utilization management programs, whether or not the particular service or treatment is payable under the terms of the provider agreement.
More stringent state requirements may supersede the requirements of this policy.
